Utilization Review

Our utilization review services help assure the highest quality and most appropriate level of care, while maintaining cost effectiveness. These include:

Prospective Review Services Prospective Review Services provide screening of proposed medical treatment requested by providers that are consistent with recommendations set forth in the ACOEM Practice Guidelines or other evidence-based, peer-reviewed, nationally recognized standards of care. This process assures that treatment is of the highest quality and delivered at contracted discount rates.

Concurrent Review Services Providing initial and ongoing assessments of injured workers receiving care in an inpatient setting. Concurrent Review Services determine the medical necessity, level of care, and appropriateness of the setting of care. Discharge plans are formulated at onset of confinement, decreasing length of stay and ensuring a smooth transition for discharge.

Retrospective ReviewRetrospective Review is a post-assessment received by injured workers to help ensure that treatment is medically necessary, compatible with diagnosis and in an appropriate setting. Reviews are completed for emergency admissions to out-of-area or out-of-network facilities; outpatient and emergency room care received in non-contracted facilities; other services to assist the provider of care in cooperating with review procedures; patients admitted to inpatient care without notification to UR; and other unauthorized care.

Medical Director ServicesThese services are a critical component of utilization review. On-staff and board-certified in occupational medicine, the medical director consults in the diagnosis, treatment and management of occupational injuries and illnesses and serves as a valuable resource for the team of professionals working to restore good health to the injured worker.